Provider Demographics
NPI:1326265893
Name:WANI, OMAR RASHID (MD)
Entity Type:Individual
Prefix:
First Name:OMAR
Middle Name:RASHID
Last Name:WANI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 S THOMPSON ST
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-8759
Mailing Address - Country:US
Mailing Address - Phone:928-226-6400
Mailing Address - Fax:928-226-6410
Practice Address - Street 1:2000 S THOMPSON ST
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001
Practice Address - Country:US
Practice Address - Phone:928-226-6400
Practice Address - Fax:928-226-6410
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA73464207RC0000X
AZ41280207RI0011X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA216317OtherABIM CERTIFICATE NUMBER
AZ432227Medicaid
CAA73464OtherMEDICAL LICENSE NUMBER
CAA73464OtherMEDICAL LICENSE NUMBER
AZ432227Medicaid